NAME: Spongebob Squarepants

DOB: 07/01/1946

CHIEF COMPLAINT: Patient is here for management of high blood pressure. 

SUBJECTIVE 
HPI-ROS: 
Patient here for follow up on his blood pressure management. He has been taking his medication
but has found that his blood pressure is still with elevated many times may takes it. He uses a
wrist monitor at home. He has not had any headaches, dizziness, chest pain or shortness of
breath. 
Past medical history is remarkable for ongoing hypertension, hyperlipidemia and diabetes. 
REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, oriented , and  very friendly. No acute distress.  
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally. 
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema. 
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs. 
Heart: Regular rhythm and rate, no s3 s4 murmurs or rubs
Chest: Lungs clear auscultation bilaterally, no rales, no rhonchi, no wheezes, 
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Normal curvature, no tenderness.
Extremities: No sinus, no clubbing,  no edema, Full range of motion. He does have mild crepitus
to flexion - extension of both knees. 
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal.
CN 2-12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.

ASSESSMENT

PLAN
1. We reviewed his blood pressure which today in offices at 174/101. We retook it 2-3 times
and remained elevated. He is not tachycardic; his pulse rate was 80. 

2. His current regimen consists of Amlodipine 10 mg and Lisinopril 40 mg and at this point
those are maxed out. We will add Hydrochlorothiazide 25 mg everyday together with
Lisinopril. Manage to blood pressure readings at home, 3 to 4 times per week. He also
has to follow up here for about 10 - 14 days. Let us know by telephone for any questions,
problems or blood pressure not responding.
3. Laboratory, he is coming due for his laboratory next month and we ordered a
comprehensive metabolic panel, CBC, Urine microalbumin, HbA1C and Fasting Lipid
Panel. 
4. He may also follow up here after his laboratory results as well in a month. But otherwise
we will see 10 to 14 days first.
NAME:  Robert Smith
DOB: 08/14/1963

CHIEF COMPLAINT: Here for follow up on his cholesterol

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness. Remarkable for occasional knee pain and some right elbow pain. Denies any
known trauma. 
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, and oriented 
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera non-icteric.
Ears: EACs clear, TMs normal bilaterally. 
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, no exudates, no lesions, no erythema. 
Neck: No JVD, no masses, no thyromegaly, trachea midline, ROM normal; no meningeal signs. 
Heart: Regular rhythm and rate, no murmurs, no rubs, no gallops. 
Chest: Lungs clear bilaterally, no rales, no rhonchi, no wheezes, normal chest movement, no use
of accessory muscles of respiration.
Abdomen: Soft, no tenderness, no masses, BS normal, no organomegaly, no bruits.
Back: Normal curvature, no tenderness.
Extremities: No deformities, no edema, no erythema, pulses intact. Mild crepitus the range of
motion for right knee and left knee is normal. Left elbow shows pain to palpation and resisted
supination and pronation over the lateral upper condyle of left elbow, no obvious swollen seen,
there is no erythema.  
Neuro: No localizing findings. Mentation appropriate. Short term memory intact. Speech normal.
CN 2-12 intact. No cognitive dysfunction. No sensory or motor deficits. Gait normal.

ASSESSMENT

PLAN
1. He is due for the laboratory again as it has been 1 year. He says he has changed lifestyle
and has lost weight since last year .For good have discontinued the Atorvastatin for right
now and he can do laboratory in 1 month consisting of his comprehensive metabolic
panel and fasting lipid panel. He cancall 3 to 4 days after his four result.   

2. As to his right knee, he has own occasional pain on it. And is not debuting on his right
elbow thus having some pain in gripping objects and twisting things like screwdrivers,
etc. But he is not finding this severe enough causing this stop to his activities. We should
give told to avoid any twisting motion and very repetitive gripping and pulling motions.
When flares up, should put ice on or use and/or over the counter non steroidal anti
inflammatory such as Ibuprofen or Naproxen.
3. Hopefully his laboratory will come back with normal values, we will discontinue
Atorvastatin at that time for the references of his laboratory. 
NAME: Kevin Smith
DOB: 12/16/1955

CHIEF COMPLAINT: Here for annual physical

The patient is here for an annual physical complaint not taking any medication and feels quite
well. 

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough.
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.
OBJECTIVE
General: Awake, alert, oriented, and very friendly.
Head: Normocephalic, no lesions.
Eyes: Pupils equal round and reactive, extra-ocular muscles intact. Conjunctivae clear, no
injection or discharge, sclera not teared
Ears: EACs clear, TMs normal bilaterally. 
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Pink and moist. Without any lesions. Oropharynx is clear. He has no tonsils visible.   
Neck: Soft, supple, no JVD, no thyromegaly, ROM normal
Heart: Regular rhythm and rate,no SVS form, no murmurs or no rubs.
Chest: Lungs clear auscultation bilaterally, no rales, no rhonchi, no wheezes, no retractions, no
use of accessory muscles of respiration.
Abdomen: Soft and tenderness, bowel sound present, has 4 quadrants, no organomegaly, No
glaring, no rebound, no rigidity. There’s no mass as palpable and no abnormal aortic pulsation.
Back: Normal curvature, no tenderness.
Extremities: No sinuses, no clubbing, no edema, pulses were intact,distally times 4 extremities. 
Neuro: CN 2-12 closed intact, No gross sensory or motor deficit, noted for range of motion, both
extremities no sensory or motor deficits, most strengths is  5/5 bilaterally, deep tendon reflexes
are 2/4 bilateral upper angular extremities, lumbar flexion and extension normal, gait is also
normal, Mentation appropriate with no short term memory difficulties cited over the interview.
intact, He has no signs and symptoms of any cognitive dysfunction, no confusion. He does
remain quite active for some exercise as he walks 3- miles per day.
Rectal : No suspicion lesion, no hemorrhoids, prostate feels within normal size, texture not
tender

ASSESSMENT Annual Physical Z00.00

PLAN
1. Comprehensive Metabolic Panel, complete Blood count with differential, urinalysis
complete with reflex culture sensitive, PSA, 
2. Encouraged him to calls ⅔ days after laboratory test are done
3. encouraged him for annual eye exam
4. Referral for consult of for screening colonoscopy was given for gastroenterology
 5. Continue healthy lifestyle and diet as well as regular exercise may fall otherwise annually
sooner/PRN
Total time spent is 29 minutes face to face with a period of 50% of his time being spent
counseling.  

NAME: Perry Jones

CHIEF COMPLAINT: Here for ff of multiple of medical issues

SUBJECTIVE
HPI-ROS:
The patient is here for follow-up on hypertension, hyperlipidemia, as well as coronary artery
disease and Diabetes. Has noted that his blood sugar has been elevated in the morning running
about 250 to 280. He also has been having occasional exertional chest pain with concomitant
shortness of breath. He has not been swaddling his leg. He is not in any fevers or/nor chills.
Denies any cough thus continues to smoke. He has been struggling to  lose weight, currently 222
pounds. 

REVIEW OF SYSTEMS:
General: Generally healthy, no change in strength or exercise tolerance.
Head: No headaches, no vertigo, no injury.
Eyes: Normal vision, no diplopia, no tearing, no scotomata, no pain.
Ears: No change in hearing, no tinnitus, no bleeding, no vertigo.
Nose: No epistaxis, no coryza, no obstruction, no discharge.
Mouth: No dental difficulties, no gingival bleeding, no use of dentures.
Neck: No stiffness, no pain, no tenderness, no noted masses.
Chest: No dyspnea, no wheezing, no hemoptysis, no cough. Exertional Chest pain. 
Heart: No chest pains, no palpitations, no syncope, no orthopnea.
Abdomen: No change in appetite, no dysphagia, no abdominal pains, no bowel habit changes, no
emesis, no melena.
GU: No urinary urgency, no dysuria, no change in nature of urine.
Musculoskeletal: No pain in muscles or joints, no limitation of range of motion, no paresthesias
or numbness.
Neurologic: No weakness, no tremor, no seizures, no changes in mentation, no ataxia.
Psychiatric: No depressive symptoms, no changes in sleep habits, no changes in thought content.
PERSONAL, FAMILY & SOCIAL HISTORY are listed on the chart and reviewed.

OBJECTIVE
General: Awake, alert, and oriented. He does ambulate an exam but he is slow during his morbid
obesity. He was able to transition from sitting to standing position and vice versa without
assistance. 
Head: Normocephalic, no lesions.
Eyes: Scleranotic tear, extra-ocular muscles intact, Pupils equal round and reactive, Ocular
fundus is benign.  
Ears: TM are clear, EACs clear
Nose: Mucosa normal, no obstruction, no discharge.
Throat: Clear, Nor does have narrow oropharynx due to his obesity and mild tonsillar
hypertrophy. 
Neck: Soft, souffle with some acantosis micropant notes, and those have a few skin tags as
well.   
Heart: Regular rhythm and rate of those heart sounds are somewhat slightly distant due to
obesity.  no  obvious murmurs, no heard s3 s4 gallops. 
Chest: Lungs clear auscultation bilaterally, no rales, no rhonchi, no wheezes. 
Abdomen: Morbidly obese, no organomegaly but difficult due to his morbid obesity, bowel
sounds are present, times 4 quadrant. 
Back: Normal curvature, no tenderness.
Extremities: Has trace edema in the bilateral lower extremities to about the mid tibias. No skin
breakdown, somehow dry. 
Neuro: Neurological examination of the feet with Monofilament testing and vibration testing
with tuning fork are negative for neuropathy. 
ASSESSMENT

PLAN
1. We discussed his Diabetes and currently his blood sugar is running above 200 in the
morning. We told him we need to increase his dose of Glipizide two 500 mg tablets twice
a day. He continues checking his blood sugar about fasting as well as 1 to 2 hour
postprandial and reports what his sugar readings are in the next 10 - 14 days. 

2. For his blood pressure, continue on his Amlodipine but are going to decrease the dosage
to 5 mg from 10 mg as he may be giving some edama on his legs due that high dosage of
amlodipine. Otherwise we will increase his Lisinopril  from 20 mg to 40 mg to hopefully
keeping his blood pressure under good control. 

3. He is due for A1C testing as well as chemistry panel, lipid testing, and urine
microalbumin testing in the next couple of months. After those tests are done for the
meantime you can leave me a messages to a front test of his glucose log so we can know
let them know if any further adjustment are needed on his diabetes medications.  
4. Stressed the importance of the annual dilated eye exam for his diabetes and he won't be
due for that until this coming June.
5. He understands all that we discussed and total time spent is 28 minutes face to face with
50 % time spent in counceling.